Heparin in Acute Stroke With Atrial Fibrillation

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Abstract
THE TIMING of heparin use in patients with stroke and nonvalvular atrial fibrillation (NVAF) remains a matter of preference of the treating physicians according to their estimation of the relative risk of early recurrent stroke vs that of hemorrhagic complications if anticoagulation is performed.1,2 Current guidelines recommend early anticoagulation only for patients at higher risk of recurrence if the infarction is not large, whereas delaying anticoagulation for several days to a week is preferred for patients at relatively low risk for early recurrence.3 However, therapeutic decisions in daily practice are complicated by the unclear risk of early recurrence in patients with stroke and NVAF.4 Unfortunately, the largest clinical trial that has prospectively evaluated the role of heparin in patients with acute stroke included patients with noncardioembolic strokes, and it is unknown whether the rate of untoward events was correlated with the biological effect of heparin, as indicated by the activated partial thromboplastin time (APTT).5 Other studies have suggested that an excessive level of anticoagulation, rather than the size of the infarction, explains most of the risk of hemorrhagic worsening in patients with thromboembolic stroke.6